A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?
13% weight loss.
Bulging anterior fontanel.
Bradypnea.
Capillary refill 3 seconds.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.
Choice B rationale
A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.
Choice C rationale
Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.
Choice D rationale
A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Erikson’s stage of initiative versus guilt occurs in preschool-aged children (3-5 years), not toddlers.
Choice B rationale
Imaginary playmates are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice C rationale
Demonstrations of sexual curiosity are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice D rationale
Negative behaviors characterized by the need for autonomy are typical in toddlers. This stage, according to Erikson, is autonomy versus shame and doubt, where toddlers strive for independence and self-control.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Encouraging the parents to rock the infant provides comfort and emotional support, which is crucial for the infant’s recovery. Rocking can also help soothe the infant and promote bonding between the parents and the child.
Choice B rationale
Administering ibuprofen as needed for pain is not recommended for infants under 6 months of age due to the risk of adverse effects such as gastrointestinal bleeding and kidney damage.
Choice C rationale
Positioning the infant on her abdomen is contraindicated after cleft lip repair surgery as it can put pressure on the surgical site, potentially causing damage and increasing the risk of infection.
Choice D rationale
Offering the infant a pacifier is not advisable as sucking can put strain on the surgical site, potentially leading to complications and delaying the healing process.
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